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RNSG 1251 UNIT 2 > ch. 19: nursing care during labor > Flashcards

ch. 19: nursing care during labor Flashcards

1
Q

What are the characteristics of TRUE LABOR CTXS?

A

-produce progressive dilation and effacement of cervix
-occur REGULARLY and INCREASE in frequency, duration, and intensity

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2
Q

Are TRUE LABOR ctxs relieved by comfort measures?

A

no

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3
Q

Where are TRUE LABOR CTXs felt?

A

in LOWER BACK radiating to LOWER ABD

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4
Q

What are the characteristics of FLASE LABOR CTXs?

A

occurs IRREGULARLY and STOPS with walking or position changes

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5
Q

can FALSE LABOR ctxs be STOPPED by comfort measures?

A

yes

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6
Q

Where are FALSE LABOR CTXs felt?

A

in the back or abd ABOVE THE NAVEL

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7
Q

When can AROM be performed?

A

when fetus HEAD IS ENGAGED

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8
Q

What is done IMMEDIATELY after AROM?

A

check FHR: the cord may be displaced by the sudden “gush” of waters which may yield a prolapsed cord

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9
Q

What are the different PHASES of STAGE 1 of labor?

A

1) latent phase
2) active phase
3) transition phase

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10
Q

The FIRST stage of labor begins with the onset of _____ and ends w/ complete cervical ____ & ____

A

The FIRST stage of labor begins with the onset of UTERINE CONTRACTIONS and ends w/ complete cervical EFFACEMENT & DILATION

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11
Q

How much does the CERVIX DILATE during the LATENT PHASE of stage 1 of labor?

A

0-3 cm

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12
Q

How FREQUENT are the CTXs during the LATENT PHASE of stage 1 of labor?

A

every 5-30 mins

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13
Q

What is the MOTHER’S RESPONSE during the LATENT PHASE of stage 1?

A

-surge of ENERGY & EXCITEMENT
-talkative, outgoing
-low anxiety

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14
Q

When is the BEST time to TEACHING?

A

-during the latent phase of stage 1

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15
Q

What is IMPORTANT to remind mothers during the first stage of labor?

A

DO NOT PUSH during first stage bc it can cause CERVICAL EDEMA
-can also cause cervical lacerations and fetal hypoxia

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16
Q

How much does the cervix DILATE during the ACTIVE PHASE of stage 1?

A

4-7 cm

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17
Q

How FREQUENT are the CTXs during the ACTIVE PHASE of stage 1?

A

every 2-5 mins

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18
Q

What is the MOTHER’S RESPONSE during the ACTIVE PHASE of stage 1?

A

-more serious
-determined, dependent, desires companionship
-RESTLESS
-FOCUSED ON SELF

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19
Q

How much does the cervix DILATE during the TRANSITION PHASE of stage 1?

A

7-10 cm

20
Q

How FREQUENT are the CTXs during the TRANSITION PHASE of stage 1?

A

every 2-3 mins

21
Q

What is the MOTHER’S RESPONSE during the TRANSITION PHASE of stage 1?

A

-AMNESIA btwn ctxs
-nausea. trembling of legs
-irritable, aggressive, frustration, fear, loss of control
-urge to push
-perspiration on upper lip and forehead
-shaking tremor of thighs
-feeling NEED to DEFECATE

22
Q

What type of emotional support can you provide?

A

-offer support and explanation
-encouragement
-breathing and relaxation techniques

23
Q

The second stage of labor is where the infant is_______

A

BORN

24
Q

The SECOND stage of labor begins w/ full cervical _____ & complete ____. It ends w/ the ____

A

The SECOND stage of labor begins w/ full cervical DILATION (10 cm) & complete EFFACEMENT (100%). It ends w/ the BABYS BIRTH

25
Q

What is the second stage of labor also called?

A

“delivery or expulsive stage”

26
Q

How much is the cervix dilated during the SECOND stage of labor?

A

10 cm

27
Q

How FREQUENT are the CTXs during the SECOND STAGE of labor?

A

every 2-5 mins

28
Q

What is the MOTHER’S RESPONSE during the SECOND STAGE of labor?

A

-sweat on upper lip
-episode of vomiting
-increase in bloody show
-shaking
-restlessness
-pressure on rectum, involuntary bearing down
-bulging of perineum

29
Q

When is the pt INSTRUCTED to push?

A

once dilation and effacement are complete, theyre instructed to PUSH w/ each CTX and REST btwn them

30
Q

The THIRD stage of labor lasts from the _____ until the ____

A

The THIRD stage of labor lasts from the BIRTH OF THE BABY until the PLACENTA IS EXPELLED

31
Q

What is the THIRD stage of labor also called?

A

“placental” stage

32
Q

How does the uterus shape change during STAGE 3 of labor?

A

from DISCOID to GLOBULAR

33
Q

What are signs of placental separation?

A

-firmly contracting fundus
-uterus shape from DISCOID to GLOBULAR
-sudden gush of dark blood from introitus
-lengthening of umbilical cord
-uterus rises in abd

34
Q

The THIRD stage of labor lasts from the _____ until the ____no longer tends to relax

A

The THIRD stage of labor lasts from the DELIVERY OF THE PLACENTA until the UTERUS no longer tends to relax

35
Q

What is the 4th stage of labor called?

A

the RECOVERY STAGE

36
Q

What can retention of tissues in the uterus lead to?

A

can lead to uterine atony and cause HEMORRHAGE

37
Q

What can you do to ensure that the fundus remains contracted?

A

massage it gently

38
Q

What are the benefits of breastfeeding during the FOURTH stage of labor?

A

-triggers release of oxytocin which lets down milk and causes uterine ctxs
-allows mom and infant to bond

39
Q

What should you ASSESS the PERINEUM for during the 4th stage of labor?

A

Redness
Edema
Ecchymosis
Drainage
Approximation

40
Q

What should you provide for the mother’s perineum after delivery?

A

an ice pack

41
Q

What is LOCHIA?

A

maternal discharge of blood, mucus, and tissue from the uterus
-can last up to several weeks after birth

42
Q

The FOURTH stage of labor is considered to be the first _____ after birth.

A

The FOURTH stage of labor is considered to be the first 1 to 2 HRS AFTER BIRTH after birth.

43
Q

What happens during the 4th stage of labor?

A

mother and newborn recover from the physical process of labor and get to know each other

44
Q

What FACTORS can influence the DURATION of the second stage of labor?

A

-presentation of fetus
-fetus position
-size of fetus
=parity of mom
-sedation
-force and frequency of ctxs
-anxiety
-emotional state

45
Q

How can you TEST fluid to determine if it is amniotic fluid or urine when there is a possble SROM?

A

-nitrazine test for ph of fluid
-AMNIOTIC FLUID IS ALKALINE (> 6.5 pH)
-normal body fluids are ACIDIC

46
Q

What are POTENTIAL COMPLICATIONS of the laboring pt?

A

-hemorrhage
-infection
-FHR bradycardia or late decels

RNSG 1251 UNIT 2 (5 decks)

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